The Center for Medicaid and Medicare Services (CMS) Review Choice Demonstration (RCD) is a review of home health agency documentation to ensure the beneficiary meets requirements of the home health coverage criteria.

RCD is a modification of the previously implemented Pre-Claim Review (PCR) for the states of Illinois, Ohio, North Carolina, Florida and Texas. Right now, RCD is well under way in Illinois and Ohio, and CMS has announced a delay for Texas until March 2, 2020, and an expected start date of May 4, 2020 for North Carolina and Florida.

RCD will affect internal processes for all departments, particularly for the clinical and billing staff.  With PDGM on the horizon and the RCD continuing its rollout just a few months after, it’s important to begin assessing readiness and staff education as soon as possible. By doing so, you’ll be able to address documentation and operational process issues and ensure a smooth transition to these new regulatory changes.

RCD’s three options

The RCD for home health services will give providers an initial choice of three options:

  1. Full pre-claim review
  2. Full post-claim review
  3. Minimal review with a 25% payment reduction

Choices 1 and 2 offer a reward for showing compliance with Medicare home health policies. Home health agencies participating in choice 1 or 2 will receive an affirmation rate every six months. If the rate is 90 percent or greater, subsequent review choices are offered a significant decrease in the claims reviewed for pre- or post-payment review. Achieving a 90 percent affirmation rate is extremely important for the future of your organizations as value-based strategies continue to evolve.

Identifying barriers in RCD preparedness

Reviewing processes in key areas of your organization can pinpoint issues that may cause problems with achieving a 90 percent affirmation rate. Below is a quick look at possible barriers home health agencies can encounter when trying to reach 90 percent.

Cash flow bottlenecks: Under RCD, there is an expected dip in cash flow within the first few months of rollout for each state. To prepare for this, agencies should assess where their current bottlenecks are. Common bottlenecks for cash flow include:

  • Unsigned orders
  • Missing/incomplete face-to-face documentation
  • Unverified visits
  • Pending discharges

EMR Preparedness: Most EMR platforms have been adapting their products for RCD, along with PDGM, but agencies should still exercise caution. Reach out to your enrollment representatives or the IT support team to schedule trainings on updates.

Staffing: Home health agencies should be assessing if their current staffing model will be linear under RCD. Start asking yourself if your billing team is adequately staffed to account for this increased work. This includes assessing current processes to determine gaps in both clinical and non-clinical staffing needs.

Training your clinical and billing teams

All areas of your organization will be affected by RCD and PDGM, but your clinical and billing teams will feel the most significant impact. It is important that adequate training take place within your agency after the RCD selection is made.

In Illinois, where RCD was implemented on June 1, 2019, these were the key documentation issues providers had to correct for affirmative billing:

  • Therapy goals not properly documented
  • Clinical form vs. narrative form for face-to-face documentation
  • Missing face-to-face documentation
  • Resumptions of care not documented within an order

To reduce documentation errors and billing deficiencies, these are topics that should be covered when training your clinical and billing staff for RCD:

  • Intake staff: Conduct training on face-to-face (F2F) encounter requirements. Obtain all F2F encounter visit notes and confirm they contain the primary reason for care and are completed in a timely manner by a qualifying physician. At the time of referral/intake, it’s crucial to obtain as much history available for that patient for any referral.
  • Clinical manager: At time of locking the OASIS, it is imperative to validate order, review of the functional OASIS questions, and frequency compliance established on the 485/Plan of care prior to sending it to the physician.
  • Clinical discipline team: Establish effective interdisciplinary coordination based on evaluations and reflective with completion of the OASIS. Ensure all therapy staff members understand how to write measurable and specific goals for each patient.
  • Order management: Without timely signatures, pre-claim submission timeframe will be slowed. Effectively manage order tracking by assessing staffing needs and ensure a strong process for confirming that all requirements are present at the time of admission for a timely turnaround.
  • Billing staff: Understand what RCD billing requires and the importance of the unique tracking number (UTN). Develop final checks as part of pre-bill process to verify the UTN is on the claim prior to submission to prevent billing rejections.

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